Independent Learning in MedEd

Lessons In Independent Learning From The Classroom For MedEd

I write on this because I have unusual, if not unique experience, in medicine and as a general psychologist who somehow became a facilitator of curricular, methodological and cultural change for school education using a central, integrated system designed by an international multidisciplinary team.

Complaining About Reality

There are a series of questions and problems that are coming up in medical education on Twitter that boil down to the culture of Independent Learning for post-graduate doctors but also apply to any graduate program and they require far more than 140 word sound bites to address them.

One side of the problem is that newly qualified specialists feel unready to cope with the rigours of their new job after leaving the protected environment of MedEd and mentorship, always having somebody to fall back and rely upon, http://www.kevinmd.com/blog/2013/12/graduate-medical-education-failing.html. They claim to be unprepared for real medical world responsibility.

The trite answer is that this is inevitably going to happen sooner or later. Sooner or later, every doctor will be thrown into the complexities and uncertainties of medical practice and be expected to swim. There is nothing that can fully prepare them for what it feels like to practice without a safety net and be where the buck stops.

The only remaining question is whether this should happen sooner or be postponed to later.

The old way was to do it sooner, literally taking newly qualified medical students and throwing them in at the deep end to see if they would sink or swim. They were really unprepared. It was extremely traumatic psychologically, even psychiatrically. It was yet more dangerous for the patients. So now intensive effort is put into delaying this event and doing everything possible to prepare the doctor for this eventual challenge and soften the blow. The time that it happens has been postponed until they have as much knowledge and experience as possible.

In a comment to Dr T Chan’s much needed defence of MedEd against these accusations, http://boringem.org/2013/12/22/counterpoint-graduate-medical-education-will-fine/, I used the metaphor that being let loose in medicine is like a parachute jump. What used to happen is that the newly qualified doctor was thrown out of the plane with only theoretical knowledge of what to do next. Now, doctors have practiced freefall in a simulator and safe landings off a scaffold in preparation. It is still going to be a little bit scary when jumping for the first time from 5000 feet but nothing compared to having done it the old fashioned way. It is a hell of a lot safer for everybody involved than the old way.

Problem resolved. End of story. It is impossible to completely remove this slight feeling of inadequacy and uncertainty but modern medical education has reduced this dramatically and maybe even optimally. To expect any more is unrealistic, especially when a host of other external pressures on MedEd are taken into consideration. Simply, they are doing a damn fine job of addressing this problem.

A Greater Perspective

However, the other side of this came up on Twitter and it got more complicated. Medical educators were talking about problems of getting doctors to adopt the culture of Independent Learning. I was shocked, horrified and angry. You mean that for all the lip service that is paid to Independent Learning in the education system, years of school, university and medical school have not indoctrinated them to the culture of Independent Learning? The students still want Dependent Learning methodology of teach recites elements of curriculum for students to regurgitate in their examination to get an ‘A’ or at least pass if they have memorised half of it?

No wonder they are unprepared for the real world when that is their attitude towards medical education. There will be no syllabus or curriculum. There is no turning round to the patient and saying ‘Sorry, my teacher did not explain that’, ‘You have got the wrong disease’ or ‘You weren’t in my syllabus’. They will have to cope with everything that is thrown at them including difficult risk/benefit decisions with multiple pathologies and all sorts of psychological and sociological factors where the answers are far from certain. And forget grades in the real world of medicine. Even straight ‘A’s is not good enough, let alone scraping by. They are going to have to get 100% first time and consistently or patients will die.

These archaic, schoolish attitudes to MedEd are inappropriate in clinical practice. They are unacceptable. They come from the traditional culture of Dependent Learning that even school education claims to have relegated to a dark past.

The educational mentality that a doctor at the top of their profession needs is the culture of Independent Learning. It is a joy and love for powerful knowledge that is independently discovered because it is needed in real life. There is a thirst for all knowledge and constant, self-motivated process of self-improvement towards perfection when this Independent Learning culture has been fully adopted. It is exactly what a doctor needs.

Independent Learning also teaches the self-confidence necessary to deal with the complexities and uncertainties of life that are everyday life in medicine. That is what these newly qualified specialists are lacking.

Paradoxically, the darkest past of MedEd did have a solution that created the culture of Independent Learning in medicine. It was to set impossibly high standards to pass examinations allied with crap incompetent teachers and methodology. It worked. Students had no choice but to become self-taught.

It really was not helpful. Worse still, in the modern world where interns and residents pay for their MedEd, it was unsalable. So teaching standards had to improve for every imaginable reason but at the same time, that made the paradox painful. The better teachers are, the more students can rely and depend on them. Catch-22. Better teaching standards appear to cause more Dependent Learning.

That only happens when the students are accustomed to the Dependent Learning culture as their norm. It is in their subconscious minds and their emotions demand it, even making hypocrisy of their well-intended words about Independent Learning. Their actions just keep slipping into the same old Dependent Learning habits. And that is obviously what has happened in the past educational experience of these doctors throughout high school, university and med school. Proclamations that this is not true are disproven by the evidence. They still want teacher to spoon feed them information to regurgitate for the sake of grades. They have been indoctrinated by example and experience to Dependent Learning.

And that is when the apparently no-win situation happens. If the Dependent Learning culture persists, the better the teachers are, the more dependent the students will try to become. They will pressurise the teacher to participate in a co-dependent relationship because that is all that they know.

The only solution is to full adopt a culture of Independent Learning.

Independent Learning is A Complete System

The first thing to realise is that a good-enough teacher is about as useful as a good-enough doctor. Neither will deliver the very highest levels of quality in the service they provide. In education, only the best teachers can create the culture of Independent Learning. However, it can be learned systematically and through the self-disciplined practice guided by knowledge and understanding.

Having said that, I really wished I was facilitating educational reform workshops to doctors with a clean slate rather than teachers with years of bad habits to erase and rewrite. I would have valued the clinician’s self-discipline and objective focus. Perhaps more importantly, the clinician has learned to adopt a more holistic thinking style in order to make difficult diagnoses in the complex contexts based on consistency and fit, the performance in explaining all of the available evidence both objective and subjective. 

This type of curricula requires this type of complex thinking. The culture of Independent Learning is a system and worldview that is complete unto itself. It is like an organic ecosystem where the function and survival of each element depends on the existence and practice of every other element. So the culture of Independent Learning has to be practiced as a whole. If any part is missing, the whole system collapses and somehow learning becomes dependent again.

There is no picking and mixing. This is a matter of high level critical reading which is life and death to the medical profession. Just because blah blah blah said something works in a different system does not mean that it applies in Independent Learning. The only evidence that counts is the evidence that has been found within this interactive and interdependent system. The international evidence is that the whole system works better than any other form of education at every level.

In fact, these systems can produce the most miraculous results or sometimes no change at all. This is not well understood within the field of academic educationalists but the former seems to happen when the background culture provides a few appropriate, missing pieces to the jigsaw that the educationalists have provided to make that whole. If society provides the wrong pieces to the jigsaw, the whole system breaks down.

For a start, the workshops to introduce and implement the curriculum required the participants to generate basic principles in education during group work so that they would own and take responsibility for the changes that needed to be made. Their idea of team working was hierarchical, passive-aggressive anarchy. Two or three would take over using impenetrable jargon as a weapon to exclude the rest who would end up silently in a corner. They would come up with every bizarrely, idiosyncratic intricacy but complete miss the really simple and obvious conclusions that they had to reach. They did not just fail in the educational sense. They achieved the exact opposite including damaging the confidence of the excluded.

If the background cultural concept of teamwork is like this, the educational system that relies on teamwork being a positive educational experience is doomed to fail. If teachers use impenetrable jargon as a weapon to assure their superiority rather than plain English to share knowledge, all that the students can do is to repeat what teacher says word for word in their exams without understanding a word of it. The gravest problems come from getting a single one of the foundational basics wrong and the house of cards is brought down.

These educational systems for Independent Learning are all about getting a wide range of basic principles right. Get them all right and the outcomes will be marvellous. Since these systems always measure outcomes, they always have teeth attached. You do not want this thing to be your enemy. You do not want to be its reluctant slave either, especially when you can be its master. If you master all of the basics, this ominous system becomes your obedient pet and you find that it gives incredible flexibility.

Class Size

Independent Learning works well with class sizes between 21 and 40 with the optimum being 28-32. These numbers come from the importance of group work in Independent Learning. It is primarily in the group work that Independent Learning takes place. Up to 80% of classroom time can be spent in group work, including presentations and larger projects.

In my experience, the optimum group size is 7-8 for formal, flat-structure group working and the optimum number of groups is 3-5 with 4 being about the best balance in practice, remembering that each group will need time to present its conclusions and discuss them with the class.

Many educationalists will go much higher than this on the principle that the more participants, the more diversity and the more likely they will come up with all of the answers rather than that being left to the teacher. Many, such as Jeremy Harmer, mention 50 as an ideal number but some go as high as 200. Even at 50, group size is starting to become unwieldy and unmanageable or the number of presentations too time consuming and repetitive for viewers if they are considering similar issues.

However, they all agree for this reason that smaller class sizes do not foster Independent Learning or its culture. If there are only 2 groups, the dynamics are of one group competing, often unhealthily, with another rather than presenting to the majority of the class. Smaller group sizes reduce diversity and discussion. In smaller groups the concept of students clarifying what they have just learned often fails and peer teaching is preferable in both ethical and practical terms.

The demand for smaller class sizes is simply the reaction to the lecture mentality in the Dependent Learning culture. It is seen as providing more access, time and attention from the teacher, which is regarded as proving the quality of the experience but is also a classic sign of Dependent Learning.

The Pro-Actively Present Lesson Plan

Of course, the great, naturally born geniuses of education do not need to formally plan their lessons. They know exactly the right thing to do. And it comes with experience too so planning lessons is just for beginners. The mark of a good teacher is not planning lessons. It is proof of just how great a teacher they are.

Completely wrong. That is old fashioned thinking from the days of dependency. The Independent Learning culture requires structure and forethought that only comes from formal, written lesson plan. More than just being prepared, when it has become a pro-active and present part of the lesson, lesson planning is

• ·         A means of maintaining focus and the structure of the lesson
• ·         An innate system of constant self-improvement for the lessons and the teacher
• ·         A system of observation with student rewards to motivate
• ·         A cultural learning tool in itself

The key is to understand that lesson planning is a long term process. The first time that the particular lesson is going to be taught, the lesson plan is a guess that is going to be tested in reality. First lesson plans are not supposed to be perfect. They are certainly not rigid. The important factor is that they are supposed to be annotated during the lesson and afterwards to see how long individual elements of the lesson took and how they could be improved upon next time the lesson is given. What worked well can be identified and repeated. Sudden inspiration by the teacher or students can be recorded and remembered. Any problems can be noted to try to think of another solution next time. Feedback is considered and included. They are also evaluated in terms of student performance in evaluations to identify which themes were effectively learned and which need a rethink and improvement.

After the lesson has been given a few times, it really does approach perfection.

So in a way, the lesson plan can be seen as an aide memoire. It also immortalises the past brilliance of students by recording their words and repeating them. The teacher really does become a facilitator of knowledge in a culture where the students hardly seem to need a teacher because they can do it for themselves. They can be as good if not better than the teacher.

This is a powerful reward system. The teacher is attentively listening to every word and noting it down. And when the teacher speaks, their words are laced with the individual and group wisdom of their students of the past, even their names. If you do not write it down, you will forget. You must be seen to write it down in the moment by the students so that they know their greatness will not be forgotten.

It is all a part of the ‘can do’ culture, a constant culture of proving just how intelligent and capable the students are. Every chance is enthusiastically grasped by the teacher to illustrate the point. They do not need a teacher. Students are capable of Independent Learning. Their confidence grows as Independent Learners.

The facilitator of knowledge surrenders the belief that teachers are the best direct teachers of knowledge and understanding. Many heads are better than one. The teacher, to whom all this came far too easily, rarely is the best person to explain a new concept to the lower band of students. Their peers, the ones that got the concept first time, are better at re-explaining the concept in words that they can relate to in their everyday life and practice.

The teacher writes all this down to improve themselves as a teacher and the lesson plan becomes student based knowledge and understanding over time. The teacher is repeating what the students of the past taught them.

Now that is cultural change. The traditional roles of student and teacher have truly been flipped by lesson planning. The traditional hierarchy of the know-it-all teacher who is better than the students can ever hope to be has been disbanded.

So why do they need a teacher at all?

The role of the teacher is in fact to provide structure to the learning environment for optimum Independent Learning to take place. The lesson plan is also the source of that structure. If the lesson plan is present and seen by all, if it is waved in front of the students’ faces to make sure that they notice its presence, it becomes a deep cultural symbol of forethought and organised thought.

A major part of teaching is teaching by example. If the example is not seen, the students learn nothing so do not be shy, as a teacher, about showing how much time and consideration you have put into structuring the lesson. Let the students see it. Give them a chance to respect it.

The presence of the lesson plan teaches prioritisation. There is not time to do every single thing that we would like to do in life, in medicine or in the classroom. This is time management. There is no time to get lost in the details and forget the basics. If we get all of the basics right and think of everything that is really important, everything comes together for the best results.

And there is a time and a place for everything. Teaching time is precious and must be put to the best use. There are other times to learn the details.

The presence of the lesson plan shows the thought, consideration and time management of the teacher to prevent side tracking and getting lost in the details. The students see just how much the lesson must cover and that there is not time for the little things.

The lesson is focused on a deep understanding of the basic principles of the theme that leads to real world mastery. That is the teacher’s responsibility, not the learning of the details. Learning the details is done by the students in their own time, from textbooks or the web, once they have mastered the fundamental concepts. It is the responsibility of the student to memorise those details and the teacher cannot memorise them for the student.

However, they might teach them learning and memorisation strategies. They will also ask the class to share any tricks that they use.

Experiential Learning Cycles

Independent Learning demands structure or it fails. There is a time and a place for everything and everything must happen at its appropriate time. There is an order in which things must happen for independent learning to occur.

There is a time for the teacher to answer questions and help the students to understand but if that happens before the students have been given every opportunity to work it out for themselves, that possibility has just been sabotaged.

There is a time for practice and application but it is right at the end of the cycle once the students have a really deep understanding of the principles that they will practice and apply. The last thing that the student needs is to get it wrong when with a little patience they could get it right first time. It will damage their confidence. This is about establishing good new habits of thought and practice through consistency so that they become second nature. Every time they get it wrong they are preventing and delaying that process. They must be given every chance to get it right first time and every time.

So Independent Learning happens in very specific order of four stages known as the Kolb Cycle of Experiential Learning, first described in 1984.

Ideally, which is the case with learning something new with a blank slate, the process begins with Concrete Experience. Realistically in MedEd, this is a case of relearning something that has been learned in the past in theoretical and usually dependent terms. It may well have been practiced before but in suboptimal terms that need rewriting, starting again at Concrete Experience and asking the students to do their best to forget their old attitudes and habits.

The very concept of Concrete Experience can be difficult for doctors in theory. It is to deal with something innately or naturally in practical terms without understanding it or really knowing what you are doing. It appears to be the antithesis of everything that they know about medicine. However, they are perfectly happy to accept this situation in terms of psychology, communication skills and the very structure of the English language that they are using all the time. Often, with routine practical skills, they are just done the way that they are done and the precise anatomy that is being dealt with is a distant memory that is rarely thought about actively.

Concrete Experience is learned by copying without understanding or questioning why things are done the way that they are done. Just get on with it. Do not ask silly questions.

And that is the response of the teacher during this stage of the Independent Learning cycle. There will be time for understanding and questions later.

Reflective Observation follows. Now the student individual or in groups reflects on why they did as they did in Concrete Experience. This must be done in their own words, words that they can truly and deeply relate to in their own lives to foster deep understanding that they can apply in real life.

In Abstract Conceptualisation the teacher teaches the formal, academic version of the subject, relating the technical words and jargon to the students versions of understanding in their own words so that they can ‘translate’ the jargon of the research, papers and textbooks that they read on the subject to their real world understanding. Any errors in the students’ Reflective Observation are corrected and their understanding placed into context, showing how far it can be generalised and its limitations or exceptions.

And the students are allowed to ask questions now!

Now the students should have a really good understanding at every level of the basic principle that was being taught in the cycle. They apply this in Active Experimentation then the students themselves, in pairs or groups, evaluate themselves compared to the principle that they have learned to see whether they were following it or not. This process continues until they have established the habit of the correct practice of the principle which has now become second nature. They do not need to think about the whys and wherefores. They can just do it.

The cycle is complete. They have returned to Concrete Experience but this is a very different Concrete Experience. They are doing the right thing as second nature supported by knowledge and understanding. They do not have to think about what they are doing but that knowledge is there in the background if ever they need it in complicated cases in order to adapt.

This forms the foundation in which they can move on to the next Experiential Learning Cycle on a new principle, building on the previous cycles. One cycle builds upon another.

The four stages of the Kolb Experiential Learning Cycle incorporate four very differ learning styles, two diametrically opposed pairs, between feeling and theoretical thinking and watching and doing. At first glance, you may think ‘That is nice. The cycle allows each person to learn using the learning style that they are best at!’

Oh this is far cleverer than that! Learning styles are themselves learned. Everybody is capable of learning by all four methods. It is just that they have learned to rely on some more than others from experience. Some they have never thought or practiced in the past as a result of their educational and societal experience. They may even have mental blocks against them.

The best way to learn is to be willing and able practice all four learning styles synergistically and learn at every level. That is exactly what the Kolb Experiential Cycle encourages and promotes.

(I must say that the moment I saw the Kolb Experiential Learning Cycle, I fell in love with it. I marvelled at its simplicity, elegance and astonishing completeness. The more I thought about it, the more perfect and wonderful it became.)

A General Methodology Framework for MedEd

The Kolb Experiential Learning Cycle is in a way the theoretical expression of optimal Independent Learning. A General Methodology Framework is the practical, step by step expression.

Plenary/Interaction – The presentation of new knowledge or a revision of old knowledge that will be necessary to deal with this theme.

Real World Examples – The real world application of the knowledge and understanding that is to be learned in this lesson in its everyday context.

Testing Comprehension – Each individual student writes answers to questions on the examples that make them carefully analyse the text and think about it. They are not expected to get the answers right, just to think about it.

Reflection in Groups – Groups are given specific tasks and questions to answer to gain a fundamental understanding of the core objective in their own words that they understand and can apply in the real world.

Presentation of Group Work – With Questions and Answers from the rest of the class followed by a class discussion.

The Teacher Teaches! – The teacher takes the rules of the students, correcting them if necessary, extrapolates them and explains any limitations or exceptions. They teach them the jargon that they will encounter in their research as it relates to their owned concepts and gives references and advice on further reading in the subject.

Application and Self Evaluation – The class now knows the concepts and put those concepts into real world practice then they self-evaluate to see how they perform according to those principles that they have learned. Teacher goes from group to group ensuring that this is occurring.

Project Work – Groups are given different aspects of the topic to research in detail and present to the class. May be a recurrent process, with a dozen or more projects being done within the cycle over weeks.

Into The Real World – The group examines real patients, helping one another. Then they discuss the diagnosis and treatment plan as a group so that they learn and integrate a wider perspective on patient management before presenting it.

Evaluation – For individuals to test their really fundamental understanding and application of the subject from first principles.

Feedback Advice – What the student is doing well and what they need to work on in future.

Re-Evaluation – Depending on what has been learned well and learned inadequately, lesson plans and even the curriculum are reconsidered to perfect them.

Understanding of The Objective

The Experiential Learning Cycle is the core and the backbone of Independent Learning but it is far from everything. It is only used for the mastery of the most fundamental principles that must be deeply understood for mastery of the subject to be attained. So it is only used when there is a specific, understandable concept that must be mastered.

It is used for new principles and concepts. It is also used to correct concepts that have been mis-learned or misunderstood, often because society has got the wrong end of the stick.

This is where the structured classroom time is important. Anything that is not profound understanding of principles is external to the Experiential Learning Cycle. It is incidental detail to the core cycle that happens to crop up in class. Usually, these are the details that it is the students’ responsibility to learn and memorise and it happens at least as well outside of the classroom structure.

So the objectives of what is to be taught using the Kolb Cycle must be very, very carefully defined and thought through. In fact there are very few of these fundamental objectives that can be taught using the Kolb Cycle.

Lesson planning is where this forethought takes place. To an extent, this is usually done for the individual teacher. The identification of these fundamental objectives that must be taught is an essential and really difficult part of designing a curriculum. That is such a difficult job to do really well that it requires massive collaboration of the very best experts. This is true to the extent that governments import the very top international experts to design their school curricula.

It is necessary to ensure the highest levels of Independent Learning. Individual teachers are rarely able to do this alone. They need central guidance. They are generally given the ‘Contents’ of what they should teach by international experts and are then left to ‘Distribute’ those contents into individual lessons according to their local experience of teaching their students to decide which of the contents will require more or less time and emphasis. They decide the details of how they will be taught.

Examples of objectives for MedEd are perhaps few and far between. Some examples would include:-

·         Dispelling any societal belief that we mainly breathe to take in oxygen when the normal drives to respiration are carbon dioxide levels and maintaining blood acid/base balance.

·         Concreting the belief of the importance of exercise in health including early mobilisation, physical therapy and avoiding bed rest in recuperation.

·         Teaching the importance of Cognitive Empathy for healthcare professionals.

·         Changing the culture of reliance on investigations rather than clinical acumen.

There are so few of these fundamental principles in MEdEd that a single cycle can last for weeks, using numerous and varied examples of real world application in group work. The cycle is the core of this work that is ever present but hundreds or thousands of other facts and details are being learned around this one central core principle. They are not facts or details that require this deep understanding and they are not being taught using the Kolb Cycle. They are being learned incidentally, almost by passive osmosis. They are being discovered rather than taught.

The teacher is only really responsible for their students understanding the core principles and instilling the culture of Independent Learning. There is a transfer of responsibility for everything else to the students. They must learn all the details by themselves.

If students discover those details because they want and need to use them in real life, their retention rate soars. A non-medical example of this is that when teaching a foreign language, new vocabulary that the teacher teaches can have as low as a 10% retention rate. It literally goes in one ear and out the other. The more that it is processed between the ears, the more likely it is to stick. If the student has discovered and used the word independently, retention rates can increase to as high as 90%.

A Pre-Mature Conclusion

I shall stop here because this ‘blog’ is already over five thousand words and heading to the length of a short e-book even in this concise, abbreviated form. Further elements of Independent Learning such as Flat Structure Multi-Disciplinary Group Work for Education will become further blogs leading to a proper conclusion.

Already what has been written represents a cultural revolution in MedEd. It is such a cultural revolution in school education that there is still cultural resistance despite trying to introduce this type of education for over half a century now. There is talk of the teacher disappearing into the background and becoming only a facilitator of knowledge but a society of students and parents have not come to terms with this concept. They still expect the teacher to teach.

Hopefully, MedEd has a easier and more cooperative audience with its students being fully trained and highly intelligent doctors who deeply value their educational experience. However, they need to know what is going on too; the importance, objectives and methodology of the Independent Learning Process so that they can actively, even enthusiastically participate in that process. And that process does offer the most miraculous outcomes in terms of both competence and culture. It even offers a solution to the question of newly qualified specialists feeling like they are being thrown in at the deep end without a parachute. 

Art, Philosophy or the The Most Rigorous, Objective Science?

I've just tried commenting to an excellent short blog http://www.meded101.com/?deeplink_referrer=socialB_twitter#!Treating-Behaviors-in-the-Elderly/c2tw/97C4DCDE-86A1-433E-AFF3-004901760BCC on the complexities of prescribing for 'behavioural problems' in the elderly. (I couldn't because of ethical objections to Facebook and that was the only way to leave a comment)

My issue was this: calling complex decision making an art rather than a science. In a world that disparages anything that is not labelled as 'science', I am uncertain of this....

Art vs science? Contextual thinking that includes the immeasurable vs linear thinking that only accounts for the instrumentally measurable?

Contextual thinking is highest level of formal logic and rationality where a theory (diagnosis or treatment plan) is debated, accepted or rejected on its performance in accounting for the entirety of the evidence available. The exclusion of subjective evidence just because it is difficult to deal with is subjectivity none the less and against science's Noble Ethic.

So should we be referring to this as rational, pro-actively objective philosophy rather than art?

Or is this is the gold standard of science that the traditions of modern academic science do not live up to?

400,000+ Reasons To Change US Healthcare Culture

I was appalled at the NYT blog http://opinionator.blogs.nytimes.com/2013/12/04/to-make-hospitals-less-deadly-a-dose-of-data/?_r=0. I was deeply sickened. 

I just had no idea that it was that bad. 400,000 deaths per year directly attributable to preventable hospital death in the US. Serious, non-lethal harm is estimated at 10 to 20 times higher, 4-8 million per year. 

I knew the figures would be worse than in the UK. The figures I have in mind from a decade ago is 6,000 preventable hospital deaths per year. Adjusting that for population size, the US figures are 1000% plus higher. If standards approached UK standards of objective patient care in the 'healthcare' system, a system that has been monitoring and treating this for years, preventable hospital deaths would reduce by 90% or over 350,000 per year.

I am hardly surprised that nobody wants to talk about it. It is an embarrassment. It is shameful. I am not surprised nobody in the medical profession can admit it, even to themselves.

In light of that, perhaps I should not have been surprised to see that this article was old evidence rather than breaking new. It was published 3 months ago in the journal of patient safety. 

http://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx

And it is a gross underestimate of the harm and death that is occurring in the US medical system to patient health. It fails to take into account the human cost of overmedicalisation and overinvestigation that occurs and is seen outside of hospital or that remains unreported, unassociated with the primary cause, the US medical culture. 50% of all radiation exposure in the US is of medical origin, leading to immeasureable cases of cancer and leukaemia a decade or more later.

The numbers engraved in my memory are a 1 in 20,000 risk from a chest X-ray and that CT uses 20x the radiation.

The culture of using the newest and latest drugs and technology is rife and a frequent horror because of a cultural lack of appreciation of the nature of drug licensing, medical licensing and clinical evidence. A drug is licensed by the FDA after alpha testing to prove positive effect. The numbers of patients in the studies are insufficient to predict  anything but the most common side-effects. Only the most immediate risks and side-effects are measured even though the patients may be taking these drugs for decades with an accumulative risk. In the alpha trials for licensing purposes, patients are chosen for lack of complexity in their health and medications. The beta-trial commences with licensing and only then do we discover how the drug performs in the complexities of real life and with complex polypharmacy.

And how long did it take for us to discover serious drug interactions with grapefruit?

The evidence of how many problems have arisen in the past during beta testing of licensed drugs produces a very simple rule. Old drugs are tried and tested. New wonder drugs are not. Each carries a significant unknown risk that will only be revealed with time.

These numbers have been excluded from the estimates of 400,000 dead and 4-8 million wounded unnecessarily by US medicine every year.

The scale of this can only be described as a crime against humanity. That such an allegedly noble and caring medical profession is a part of this atrocity, collaborating and participating in it, nauseates me. 

I really do feel physically ill. Words fail to express the visceralness of my reaction.

Still, I am incredulous. I cannot believe that this is not at the forefront of every medical mind in the US. I cannot believe that these horrifying numbers are not a constant motivator of dramatic change from inside medicine to restore the honour and reputation of the profession as healers not killers. 

But all I hear from many US doctors is about massaging medicine's image, not changing the reality. Claims of compassion and humanity sound good. There is talk of empathy without definition when behind the words it is not empathy but sympathy. Not a mention of the facts or evidence. Nothing said about improving those. Just complaints about EBM from those who have missed its fundamental principles http://clinicalarts.blogspot.mx/2013/12/when-evidence-based-medicine-was-best.html.

I know that there are many, many doctors out there who want to be ethical and save life rather than destroy and take them. I know that they have the highest intentions. The problem is that their strategy is culturally wrong and ineffective. It has been making the problem worse.

Insanity: doing the same thing over and over again and expecting different results. 

Albert Einstein 

It is time to identify the problem and resolve it. The first stage of problem solving is to admit the problem. Attempting to solve a problem by continuing the strategy that caused it just makes the problem worse. A change of strategy is needed.

This evidence has brought together the importance of various individual blogs on this site including the use of the dark arts of sales to sell an inferior, non-life enhancing product to an unwitting consumer. It is passive aggressive Win/Lose Lose/Win sales in which everybody will lose in the long term. You should read them all because the individual blogs come together to paint a very different worldview of healthcare in which patient health outcome is prioritised by selfless doctors, doctors who really care about their patients' health.

The US is the birthplace and home of sales. It originated the outdated belief that the customer is always right in early sales psychology. Manipulate the unsuspecting and innocent customer and indoctrinate them into what they expect for your own profit. It is just to sell for your own benefit in the short term. The long term outcome has been that US patients are the least satisfied with the standard and quality of care in the whole world.

This is the darkest art sales strategy and it is still being used in US medicine. It is being sold to med students and doctors too. When I hear words like 'humanity', 'empathy' and 'compassion', I know they are hollow. They are said because they sound good. They will sell. I know they are just sales and a sop to a shallow shell of self-image to prevent insomnia. 400,000+ deaths per year is the proof of the vacuum behind them. It is just a worthless con. It is words without action,

Yes, this lowest common denominator of dark sales has started to be used in the UK by governments hoping to be re-elected health budgets and cutting services at the cost of patient health. It is being used to con voters and hide the truth of what is happening.

Leaving health reform to market forces and patient demand sound good in theory but they are the cause of the problem. That is how the system has got into the mess it is in today. The public has been misinformed, disinformed and uninformed about health and just about everything else in their lives. They don't know what they want and they don't know what they need. The sales and marketing department has decided for them.

The only information on which to base patient choice has been reputation and customer satisfaction. Reputation and satisfaction is bought by spending on dark arts sales and marketing and has nothing to do with the quality of care. Expectation and demand have been manipulated.

As specified in the NYT article, the actual facts and figures have been hidden on which they could have made rational decisions. They objective performance of hospitals in saving lives, or rather killing patients through ineptitute and errors, has been denied to them. It is being blocked by hospital lobbyists.

This is life and death freedom of information that is being denied to the public.

This hard data is the one and only way to change what is happening and stop hundreds of thousands of hospital induced deaths and millions of casualties per year. Some of this life and death information is starting to become available. It is the thin end of the wedge and this is by far the biggest issue in healthcare. 

I might even suggest that Obamacare is just a distraction. Or perhaps it is a step in a greater plan to get doctors into centralised groups to make them easily controllable?

So individual American doctors and the US medical profession as a whole are going to have to choose whose side they are on when this blows. Objective health measures will replace customer satisfaction. You really do not want to be on the wrong side of this when it blows. They must choose objective patient health or dark sales strategies. They must choose their individual and professional reputation or a sham that will be shattered by the hard evidence.

You really want to be on the right end of that stick or the consequences will be catastrophic. 

So that is the choice. Those are the facts. It does not matter if you Facebook like them or not. It does not change those facts. Face up to them. You can either be behind a cultural medical revolution, leading a revolution for better objective health for your patients and all patients or you can be held accountable and punished. 

It is time for doctors to take this into their own hands.

When Evidence Based Medicine Was Best for Patients' Health

I was privileged to have been trained and worked in the imperfect Halcean days of UK medicine. It was far from perfect but it was rapidly accelerating in that direction, perhaps because it was led by senior doctors who had lived at the top of their vocation based entirely on doing their best for the patients and their health.

It was these doctors that invented and designed Evidence Based Medicine. They did so selflessly for their patients' long term health.

That original EBM, created by doctors for patient health, has saved lives immeasureable. It is Evidence Based Medicine that brought the importance of lifestyle into full focus.

One of the most important advances was to test old wives' tales that had never been tested. Bedrest and exercise avoidance were found to be major disablers and killers rather than helping the body to recuperate and improving prognosis. Unproven assumptions, like hospital is the best place to be when you are even the tiniest bit ill and the safest place to be if you are not particularly ill just in case you do get ill, were tested and catgorically disproven.

Specialist care must be the best care!

No, not unless you really need specialist care. A well trained primary care doctor provides safer care for the generally well population. They are used to caring for that well population and do so with common sense. The mind of the expert is coloured by their world and experience. Show them a well person and they treat them as a severe case. They overinvestigate and overtreat generally well patients.

One of the great advances of Evidence Based Medicine was to bring objectivity and thought to every treatment decision. It was EBM that brought the culture of intensive evaluation of side effects of investigation and overmedication. The risk benefit decisions became more difficult, more personal and a risk benefit analysis had to seriously be made before doing anything.

X-rays and CTs cause leukaemia and cancer and were only to be used if they changed management. More invasive procedures had significant immediate mortality. Even the safety of newer radiological techniques such as MRI and ultrasound was questioned in light of the terrifying number of decades and patients investigated with X-rays before those risks became clear.

Then there were the indirect risks of all investigations, even the most innocuous such as a blood test. Their risk lay in the false positives and negatives. By their definition of 'normal', most blood tests automatically have a 5% false positive rate. In standard batch testing used for a simple blood count and checking electrolytes, it is statistically abnormal to have all normal results. MRIs have an incredibly high false positive rate for detecting musculoskeletal conditions that do not exist clinically and hence do not need treating surgically. And abnormal results in normal people become justifications for more invasive tests and unnecessary treatment.

Evidence Based Medicine returned the power to the clinician and their acumen at a time when they were under threat from the wonders of medical technology. The best diagnosis was the clinical diagnosis, aided where necessary and appropriate by the machines.

It also provided excellent sources of multidisciplinary rather than peer reviewed medicine, such as Cochrane and NICE, a higher standard in the life and death world of health and especially important because study design and statistics are so difficult. They are difficult. This is a higher standard than typical academic science. Even major scientific journals are not good at it as specialists in the field often lack independent objectivity and statistical skills. Grass root doctors cannot be expected to be able to constructively criticise.

So guidelines were created to help doctors in light of the massive amount of clinical papers and journals available. They were assessed by the highest experts in the field. They were guidelines of first line treatment for average, uncomplicated cases and vague guidance in more complex cases. Exceptions for those exceptional cases were made according to clinical acumen in the individual case. And if the first line did not work, it was up to the clinician.

These guidelines did improve patient health. They gave patients an assured standard of practice wherever they went. And doctors were no in conflict with one another's opinions.

And higher medical standards have forced pharmaceutical companies into higher standards in their studies. Many old drugs were re-evaluated. Several failed. Several had been accepted on theory and failed in real outcome in real life. Several had not had their side-effects fully evaluated and were prescribed on hope rather than evidence.

The monopoly of surgery and pharmacy was broken. The previous medical culture, Theoretically Based Medicine, was biased and rejected other therapies because science did not find the theories behind them scientific enough despite the evidence in the real world. This did not just include acupuncture or relaxation therapies. It is still difficult to see 'scientific' theories for physiotherapy and psychology.

It was simple. The therapy that had the best benefit/risk profile was the best whether science or doctors liked it or not. That was irrelevant. The best therapy for the patients' health should be used or recommended. Particularly in minor and self-limiting illness, where the benefit of any treatment is marginal in long term outcomes, often pharmacy and surgery lost out.

So this was the dream. The original EMB was to improve health. It was a moral crusade for an ethical medical profession. It was a selfless crusade that was not always in their interests in the short term. However, it was to answer any criticisms about the medical profession and preserve their honour, reputation and public trust.

It was also teamed with other practices to improve doctors' performance and improve standards, such as continuing medical education, audit and a 'no blame' culture of openly examining every negative event in multidisciplinary groups as a learning experience to all in order that misjudgements were not repeated, even other people's misjudgements.

All this was organised and instituted by highly ethical doctors for the good of their patients' health.

A sign of those ethics at the time was that 50% of primary care agreed to manage their own budgets. They would make savings by curing over-medicalisation and taking on the responsibility of less investigation, less hospital referal and less hospitalisation. They were taking on responsibility for the high level work that hospitals had previously been doing. They would not be delegating that work.

They would receive no extra pay for more hours and more responsibility. What they would receive was extra benefits for their patients from the savings they made through the highest levels of practice. They could have visiting specialists or in house physiotherapy and psychology to cut down on hospital visits and waiting times. They could even have relaxation classes or Thai Chi teachers brought in as exercise for the elderly to keep them fit and healthy.

50% or more of UK primary care took this offer of much more work and much more difficult work for the same pay for the good of their patients.

It was not about cost cutting or rationing. It was an ethical quest for gold standards in patient health. It just happened to cut costs coincidentally by reducing hospital stays and drug/investigation costs.

Evidence Based Medicine trims the fat to make healthcare lean, fit and of the highest quality. The problem is that the government wanted its pound of flesh too and to cut healthcare to the bone. That is when it put in administrators, management consultants and beancounters who did not understand healthcare or its noble culture to replace doctors and other healthcare professionals that did. 

They succeeded. They cut costs and corners in the name of efficiency statistics. They devasted the noble ethical culture by teaching doctors to think like managers, even speak like them. They taught them to think like penny pinching beancounters.

This created another form of 'Evidence Based Medicine' that was cost centred not health focused. It was not about health outcomes any more. It became about making care average, not excellent. It was for the benefit of the government and the administrators, not the patients.

It is when guidelines became protocols and clinicians were not allowed to make exceptions for exceptional cases. They were not allowed to think for themselves. They had to do the cheapest thing in the short term regardless of the long term health costs. Medicine was cheapened.

The nobility of the medical profession was cheapened and tarnished.

And that just about sums up the flavour of Evidence Based Medicine that is being imposed on the American medical profession by the insurers. It is not driven internally by ethical health professionals to improve health. It is imposed externally by administrators and beancounters with no medical experience and without medical ethics.

THE DISEASE OF SUBJECTIVITY

The dangers of the disease of subjectivity are well known in psychiatry. It is called Borderline Personality Disorder and it is accelerating to reach epidemic proportions. It is simply a lack of self-discipline and self-control over the emotions. It is where the ‘heart’ is allowed to completely rule the head. It is the victory of the subjective emotions over rationality and objectivity.

The hard facts of this disease are horrifying. The rates of clinical anxiety and depression are staggering for those that choose the emotions over rational and objective thought. It is hardly surprising. Their unwillingness to think and make rational decisions predictably trashes their lives in every way. They make such a mess of their lives that many of them recurrently self-harm and attempt suicide.

However, they should not be considered as the sufferers because they have chosen this path. The real victims are those around them that suffer the consequences of their over-emotional decisions and total lack of morality. Nothing matters to them except how they feel at that moment. They do not care about the side-effects that they cause for others. Truth is irrelevant. They lie and manipulate pathologically to get their way.

They choose to live in an entirely subjective world. Objective truth is irrelevant.

The jargon name for the therapy that has been clinically proven to effectively treat this voluntary insanity is Dialectic Behavioural Therapy. There is nothing complex about it. It is simply forcing them to understand that there are consequences to their actions. It is forcing them to face reality including how sooner or later they make everybody in their lives hate them.

Unfortunately, psychological and medical texts on the matter cannot tell the objective truth about Borderline Personality Disorder because prospective patients might read them and their egotistical emotions might be offended. They would be far less likely to turn up for therapy if they understood the truth about their condition. They would not turn up if they knew that the psychologist would not be manipulated into seeing the world from their perspective. They would not turn up if they understood that the objective of therapy is to change them and make them more rational.

They think that anybody telling them what to do to make their lives better is an affront to their rights. It is limiting their freedom. Their idea of freedom is a libertine concept of total irresponsibility and thoughtlessness. In their subjective Lalaland, it is their right that their words and actions have no consequences. In reality, they think that everybody else should pick up the tab and pay for their ‘freedom’.

It is this lack of mentality that academia is fighting.

DEFENDING OBJECTIVITY

Fortunately I am preaching to the nearly converted on the subject of objectivity. So the objective truth about subjectivity and emotions can be bluntly clarified here without anybody getting too offended. Only the social side of the readers is going to be offended by the truth that the rest of society does not want to know about subjectivity and the emotions.

Anybody involved in science or academia should know all about the emotions because they are the fundamental enemy and gravest threat to their vows to objectivity in their work. They should want to know the absolute truth in very simple words that apply to real life and can be used in real life. They must know if they are to fulfil their promise to society on which they are granted such trust, respect and status.

Most will want to know as a matter of personal pride in their work and their dedication to the sacred quest for truth about the world that we live in.

The rest of society has no interest in understanding what emotions actually are. They simply do not want to know. All that they are interested in is pandering to them and slavishly, sheepishly obeying them. They are not interested in who their master is, preferring myth to reality.

Society glorifies emotions, calling them things like love. They have absolutely no understanding of the truth of the matter in terms of proven psychological knowledge. They do all that they can to avoid the truth of the matter because knowing what the emotions really are would instantly end their adoring worship and trusting faith in their subconscious mind.

There is nothing mystic or special about the emotions. They are nothing more than the chemical physiology of stress and relaxation. Everything is known and understood about them in science and psychology. There is no mystery. It is just that few what to know the facts about their master.

They want to believe that their emotions actually belong to them and define who they are. Nothing could be further from the truth. The emotions force us physiologically to copy others. There is absolutely no originality, creativity or inspiration in the emotions or the subconscious mind. They are sub-conscious, less than conscious, below consciousness. Creativity, originality and inspiration come from a higher level of the in every psychological or spiritual model.

The emotions are the opposite of intelligent. Emotional Intelligence is a complete misnomer. Whilst the description of the ability to move beyond focused, linear logic and build jigsaws of a wide variety of information and evidence to come up with a theory or decision that is consistent with everything is extremely important, calling this Emotional Intelligence is dangerously misleading disinformation. It has nothing to do with the emotions. In fact, the emotions are our subconscious mental blocks that prevent us from using this jigsaw or contextual logic.

The emotions are exactly what hold people back from pursuing this higher logic that has been recommended by academia from antiquity. It has always been acknowledged as the highest form of rationality and objectivity. The very definition of how a theory should be devised, accepted or rejected is based on this contextual or jigsaw logic. The rules were always that theories should be accepted or rejected according to their performance in explaining all of the available evidence. Theories should always have been devised like a jigsaw and judged on their consistency rather than linear arguments.

They claim that their emotions make them human when they are exactly what turn them into a dumb and predictable computer that has been programmed by others. The only difference between the emotions and a programmed computer s that the computer has been programmed by competent and responsible programmers. The emotions have been programmed by a thousand incompetent and irresponsible programmers, even malicious programmers and all the programs are inconsistent and pulling in different directions.

Anybody with more than half a wit who has actually used that wit to think about the question of what separates humanity from the animals will have worked out all by themselves that it is our ability to think rationally that is the great human difference. It is our conscious thought that makes us better than the dumb beasts.

It is the emotions of the subconscious mind that stop us from thinking rationally about such questions. It is almost as if they know the conclusions that we will inevitably come to and play every dirty trick in the book to stop us from going down that path and exposing their true nature. In fact, the emotions are nothing more than an evolutionary remnant from our animal past. All animals have them. They are an unnecessary and inconvenient throwback from our childhood and are completely worthless, even worse than worthless in the damage that they cause for an adult.

The lowest common denominator of society will not like this truth. Our society is insanely subjective or it would be if only psychiatry had a rational definition of insanity. Unfortunately, psychiatry’s core definition of insanity is itself subjective and based simply on ‘normality’ being as insane as the norm. So long as you think, believe and perceive like everybody else, you are okay. It is okay to follow and become the lowest common denominator because that is just what everybody else does.

EVERY DECISION IS A THEORY

Good decision-making is the fundamental life skill at every level. It applies everywhere. It applies in our personal and social lives. It applies in our professional lives. It applies in academia and science.

The process of good decision-making is exactly the same as devising and testing a theory in science and academia and science. Every conscious decision that we have actually thought about is a theory that we will test. We do the very best with the information and understanding that we have of the situation and predict outcomes for the options in front of us in order to choose what to do.

The stakes are high. We are going to stake our wellbeing, even our lives on those decisions. They have better be right first time or we are in trouble. Like in academia and science, we must be realistic and objective rather than basing our decisions on the fantasy of subjectivity and wishful thinking.

This is what we are learning in school. It is one of the fundamental purposes of compulsory education in our society, to prepare us for a life of good decision making. It is the culture of academia and science that we are learning and the learning the culture of academia and science, becoming indoctrinated in it, is the tool to make intelligent, informed and rational decision making second nature.

Theories and decisions are inseparable concepts in reality. Science and academia are also the source of those theories on which we are going to base our life decisions. Our life should be managed and dictated by the application of the theories of academia and science.

The rules of good decision making are the same in all forms of life. They are the same as the founding laws of good academic and scientific practice. We need objectivity and rationality as laid down in the most basic rules of formal logic. We need to question and to know. We need the genius and inspiration that is so prized in academia and science.

Repetitive Strain Pain From Typing

Pain in the forearms, wrists and hands is a modern day epidemic. We cannot live or work without a keyboard and mouse and that results in a constant stress on the muscles and tendons of the forearms and hands. The necessity of the keyboard and mouse in our information age also makes the traditional treatment of resting them inconvenient or impossible.

So what can we do?

The first question we must ask ourselves is whether this is repetitive strain injury, which is an inflammation of the tendons. This will not only cause pain when the hand is moved but also there will be tenderness over the tendon itself, most commonly at the elbow. However, there should be no external signs of anything amiss, like lumps or bumps that may even move when the fingers move. Those may require surgical excision.

The most common problem that mimics repetitive strain injury is a trapped nerve in the neck due to excessive tension in the neck muscles. When a nerve is squashed, it causes pain in the area that the nerve supplies. All the nerves that supply the hands and forearms come through the neck. There may be no pain in the neck itself or it might feel a little stiff. It can also be associated with headaches when using the computer. However, there will be no tenderness at the site of the pain.

Setting up the workstation is the first step in reducing or curing either of these problems. The key is to be in a comfortable position where the stress on the body is kept to a minimum. This not only relaxes the neck and shoulders but also decreases the muscle tension in the forearms since the muscles are not fighting against one another.

Most people type with their screen far too low, especially when using a laptop. For the neck and shoulders to be relaxed, the screen should be at eye level and it should be at least 2 feet (60 cm) away. A simple box under the monitor is the easiest solution. If using a laptop for prolonged periods, it is best to buy a separate keyboard and mouse so that you can separate them from the screen in terms of both height and distance.

Learning to touch type is essential. If you are forever looking down at the keyboard to see what your fingers are doing, you are asking for problems.

You should sit upright in your chair with the upper arms hanging straight down from the shoulders. It is best if the elbows should be supported by a chair with arms at this level. Ideally, the keyboard should be very close to your stomach, a little lower than with a desk which is why keyboard drawers are advisable. Most people can cope with the height of a normal desk so long as they can rest their wrists just in front of the keyboard.

Quick, short term relief from stress during a stint working under imperfect conditions is to lie face up on the floor with a rolled up towel between the shoulder blades. Look at the ceiling, not at the wall behind you. The arms are held at just above shoulder height, palms facing upwards and let gravity stretch out the muscles at the front of the chest while relaxing those of the shoulders and neck for five minutes.

The Next Step

Setting up the workstation for good posture is essential in preventing and minimizing problems but if those problems have set in, other intervention may be necessary to resolve the problem quickly and efficiently.

The first line of professional help in these matters is available from physiotherapists, chiropractors, osteopaths and Chinese physicians trained in acupuncture. All are recognized, evidence based treatments of these conditions. In many ways, they are to be recommended over medical treatments for all but the most intractable of cases because of the relative absence of potentially serious side-effects. In fact, a doctor may well send you off to see a physical therapist for heat or ultra-sonic treatment, even acupuncture with a physiotherapist if you have not tried that first.

The Need for Plain English

Plain English. Yes. What is the purpose of communication?

It is for the other person to understand what you want to say. It is common sense and common wisdom. If you have something important to say, say it in words that everybody can understand.

This is a really important part of modern teamwork in the commercial world where decisions count. The use of Plain English rather than confusing jargon allows every member of the team to understand all of the issues involved and to integrate knowledge from all of the experts that are a part of the team or who advise that team. Then the team can come to the best, most balanced decision that takes into account all of the experts’ perspectives and knowledge.

Plain English integrates knowledge for the sake of the global context. Jargon fragments knowledge and prevents a clear picture form being formed. It creates conflicts between individual subjects in which they compete to feather their own nest at the cost of everybody else. The effect of jargon is that it disempowers outsiders from making a viable input leaving only the experts with a valid opinion and all of the power.

Industry has learned costly decisions from the bad old days. The use of Plain English is objective evidence that translates to the reality of commercial success. The team makes the best balanced decision.

The IT expert wants new toys with IzQ 31n4d hyperchips with RAN 72.943 technology on a Hoopo Poopoo X motherboard. The specifications are blinding. It will allow alta-net mega communications with the HK 4321 oncoboard sockets in a seamless infra-gold virtual interface....

I’m sure it is all true. We all nod our heads knowingly to hide the fact that we have absolutely no idea what any of this means. Yes, yes, yes. We all agree and soon we all have new fluorescent green plastic boxes on our desks with a squared rainbow of flashing lights. Well, the lights of the neighbouring desk dance joyously hypnotising my boss into such a stupor that she fell off her chair. Mine do not dance as yet. I am still waiting for my training course to turn the darned thing on.

Those flashing lights also distracted the only person in the office (apart from the cleaning staff) who actually gets any work done, my boss’s secretary. Believing the IT Manager to be the culpable idiot, she ignored his advice and said that something could be done about the problem. As soon as he was gone, I saw her putting a black plastic bag over here blazing tower, which of course literally started to blaze after a few minutes.

Of course, I accidentally forgot to mention this to the IT Manager, perhaps because his main pleasure in life is trying to make other people look stupid in front of their co-workers. That will teach him for being so condescending all the time and it has worked. Everybody now thinks that he is stupid for buying unreliable, experimental technology. I do feel a little guilty though that all of the computers have now been returned to the manufacturer who are desperately trying to work out what sort of internal failure nearly burned down out office but at least we have the old ones back again.

Best of all, the boss’s secretary is happily working again. Her word processor and spreadsheets are back on line, whatever that means. ‘No more bugs’, she says.

If only we had listened to her, but she is no expert. Personally, I think that her whacky ideas of hiring more secretaries or, failing that, teaching people in the office to use their keyboards with more than the index finger might well have been money better spent. But who would listen to her?

And perhaps they should have been more respectful of the Marketing Manager’s opinion. That appeared to have cost us half our jobs, including that of the Technical Director.

The new design was full of such wonderful technical innovations and high-tech wizardry that we all thought that the Technical Director was right about it being a sure fire success. We were just flabbergasted at how good it sounded, all of us except for the Marketing Manager who tried to put a dampener on things by saying that it was simply too ugly to sell. Oh, and the bean counter who said that it was not cost effective to build.

Things really could only have got better in industry with the introduction of teamwork and the experts being forced into explaining everything in words that everybody can understand. Now everybody is included in the decisions and can participate.

The best team leader is an unbiased generalist who knows at least the basics of what each expert is talking about. Many companies in the modern world even send their management trainees through all of the different departments to methodically create a true generalist for the job of leading the teams and bringing the knowledge of the experts together into a comprehensible whole.

It was an important lesson from Japan to include the workers themselves rather than leaving them out and leaving it all to the experts. That is where most of their pioneering ideas in manufacturing came from, the common sense factory floor and the people who were actually doing the work. The ordinary person is the one with common sense and who sees the problems with the basics.

If all of the basics are right, you cannot go far wrong. One basic error in the foundations and you will have a total disaster on your hands.

The best decisions are the decisions that take all points of view into account.

The common person must be included in the debate and for that to happen, they must be informed.

And it is the use of common language that brings together all of the knowledge of many subjects. It allows experts to be understood and you would have thought that that was what they wanted....

Or would they want to bamboozle us and blind us with science to get their own way, exclude us. Worse still, I have seen non-English speaking cultures in which language is deliberately used as a weapon of class and status. It is used in this way as the direct opposite of its real purpose of communication. There is no intention of communication and the last thing that is proposed is that the other understands the issues. Instead, the most complex and convoluted language possible is used to damage the self confidence of the other and put them in their lowly place.

Incomprehensible jargon or structures are used as a tool of unquestioning obedience in cultures that still have the master and slave mentality and hierarchy. It both massages the ego of the perpetrator and damages the self-confidence of the person of lower status. It opens the way to corruption and the abuse of power by making people powerless.

The Campaign for Plain English is a very major educational issue too. Plain English allows deep understanding and the application of a theory in the real world and is hence advocated in the methodologies of Independent Learning. Jargon is a part of memorisation of somebody else’s words for repetition in an examination and is hence discouraged, kept to a minimum in modern education. It does not foster understanding or real world application. It is difficult to process the theory outside of its narrowly defined and taught limits. The knowledge becomes merely academic.